Asbestos Abatement Contractor Application

3017 N. STILES., OKLAHOMA CITY, OKLAHOMA 73105 ∙ www.labor.ok.gov ∙ PHONE: (405)521-6464 ∙ FAX (405) 521-6016
Revised 2011-Jan Oklahoma Department of Labor
Mark Costello
COMMISSIONER OF LABOR
ASBESTOS ABATEMENT CONTRACTOR APPLICATION
☐ NEW ☐ RENEWAL LICENSE #
1. Applicant’s Name - 1st Responsible Party
2. Doing Business As:
3. Social Security Number
4. Date of Birth
3. Address
4. City
5. State
6. Zip
7. Phone
8. FAX:
List the name and address of the Service Agent:
1. Name:
2. Title & Capacity:
3. Address
4. City
5. State
6. Zip
List the names and home addresses of the officers, principals, partners and proprietors.1. Name: 2. Title & Capacity:
3. Address
4. City
5. State
6. Zip 1. Name: 2. Title & Capacity:
3. Address
4. City
5. State
6. Zip 1. Name: 2. Title & Capacity:
3. Address
4. City
5. State
6. Zip 1. Name: 2. Title & Capacity:
3. Address
4. City
5. State
6. Zip
2nd Responsible Party (If applicable)
Name of Responsible Party:
Please indicate all current Oklahoma asbestos licenses and the license number: CHECK TYPE LICENSE LICENSE NUMBER CHECK TYPE LICENSE LICENSE NUMBER
Worker
Inspector
Supervisor
Project Designer
Mgmt. Planner
FOR OFFICE USE ONLY
FOR OFFICE USE ONLY
Date
DEO
Receipt No.
License No.
Asbestos Admin Approval/Date Type of Payment
1 2 3
#
Endorser 3017 N. STILES., OKLAHOMA CITY, OKLAHOMA 73105 ∙ www.labor.ok.gov ∙ PHONE: (405)521-6464 ∙ FAX (405) 521-6016
Revised 01/09/2012 PLEASE SUBMIT COPIES OF THE FOLLOWING:
1. Original Contractor/Supervisor training class and all subsequent refresher classes*
2. Other asbestos training classes*
3. Proof of workers’ compensation insurance coverage or a notarized statement explaining why such coverage is not mandated by law.
*Training must have been provided by an educational institution, government agency or labor union and must have been accredited by the U. S. Environmental Protection Agency.
I hereby authorize the educational institution(s) to release verification of completion of the courses presented in this application.
I, upon my oath, do state that the above information is a true statement, and further state that I am not under any type of disciplinary action, including license revocation or suspension, by any State or political division thereof, or by the United States government, for any illegal or improper activity, civil or criminal, involving asbestos-containing material.
Applicants Signature Date
Please list all locations in all states in which the Contractor has performed abatement of friable asbestos materials. Include the name and address of the local asbestos procedure enforcement agency(s) for each location. 1. Name of contracting authority:
Address of contracting authority:
Name of enforcing agency:
Address of enforcing agency:
City
State
Zip
Project name:
Project address:
City
State
Zip
2. Name of contracting authority:
Address of contracting authority:
Name of enforcing agency:
Address of enforcing agency:
City
State
Zip
Project name:
Project address:
City
State
Zip
3. Name of contracting authority:
Address of contracting authority:
Name of enforcing agency:
Address of enforcing agency:
City
State
Zip
Project name:
Project address:
City
State
Zip 3017 N. STILES., OKLAHOMA CITY, OKLAHOMA 73105 ∙ www.labor.ok.gov ∙ PHONE: (405)521-6464 ∙ FAX (405) 521-6016
Revised 2011-Jan OAC 380:50-5-5 of the Abatement of Friable Asbestos Materials Rules states: Licensing of Asbestos Abatement Contractors are as follows: (1) Applications shall be submitted on forms prescribed by the Commissioner. Submission of such application shall include a non-refundable one thousand dollar ($1,000.00) processing fee. (2) After the statutory one hundred twenty (120) day waiting period, if a Contractor’s application is accepted, the Contractor will be notified by the Commissioner and required to submit at that time the five hundred dollar ($500.00) license fee. (3) The applicant shall designate a minimum of one, or a maximum of two, responsible parties to be named on the license. Such responsible parties shall have and maintain the training credentials required for licensing. Documentation of satisfactory completion of the required training and all subsequent refresher training shall accompany the application. (A) In the absence of such responsible party in the employee of the Contractor, the Contractor will not be allowed to perform asbestos abatement work in the State of Oklahoma. (B) The responsible party shall have successfully completed and shall have documentation provided for not fewer than two asbestos training courses. One such course shall be an Asbestos Abatement Supervisor’s course which fully meets the requirements of OAC 380:50-6-3 and 380:50-6-8. The Commissioner shall maintain updated lists of additional training courses acceptable for licensing. (C) Responsible parties may be changed or added to the license at any time, by paying a fee of fifty dollars ($50.00) per change or addition. Documentation of satisfactory completion of required training and all applicable subsequent refresher training shall be submitted. (4) Prior to issuance of the license, the Contractor must have a respirator program meeting all requirements of OSHA or DOL, whichever is most stringent. (5) Licenses shall be issued for a period of one year. (6) No Contractor may perform any asbestos abatement after expiration of the license. (7) If a Contractor allows the license to lapse for more than thirty (30) days, the license may not be renewed, and licensing will be permitted only after meeting all requirements for a new license, including the one hundred twenty (120) day waiting period. (8) License applicants must be of good character. Conviction for a felony by an applicant, if a proprietor or partner; by an officer, if a corporation; or by a responsible party, shall be grounds for denial of, or revocation of, a Contractor’s license. (9) The Commissioner may refuse to issue an Asbestos Abatement Contractor’s license to any applicant, if there are records of Notice of Violation (NOV) of NESHAP regulations by the applicant, or any principal, partner, or officer of the applicant’s firm or associated firms, as maintained by EPA.
4. Name of contracting authority:
Address of contracting authority:
Name of enforcing agency:
Address of enforcing agency:
City
State
Zip
Project name:
Project address:
City
State
Zip
Please submit the following with this application:
1. Approved Respirator Program
2. Operations & Maintenance Program
Please check one of the following:
NON-EXEMPT
New applicants only must submit check or money order for $1,000.00 made payable to the Oklahoma Department of Labor as a non-refundable application fee.
OR
EXEMPT
The state and political subdivisions thereof shall be exempt from any certification fees when such entities act as a contractor.
In accordance with Title 40, Section 452, Oklahoma Statutes as revised, there is a mandatory one-hundred twenty (120) day waiting period to allow the Asbestos Division to investigate the work record of the Applicant. The license may be denied to an Applicant whose past performance for abatement of friable asbestos does not comply with Federal and other State’s requirements.
Providing false or incomplete information on this Affidavit/Application will be grounds for rejection of this application, or for suspension or revocation of the license, if issued.
At such time as the application and respiratory program are approved, the Applicant will be so notified. The Applicant at that time will submit the Five-hundred Dollar ($500) annual license fee, and the license will be subsequently issued. 3017 N. STILES., OKLAHOMA CITY, OKLAHOMA 73105 ∙ www.labor.ok.gov ∙ PHONE: (405)521-6464 ∙ FAX (405) 521-6016
Revised 01/09/2012 Foreign corporations must be registered with the Oklahoma Secretary of State.
Any supplemental information submitted with this application must be signed by the Applicant and notarized.
All agencies listed in this form may be contacted by the Oklahoma State Department of Labor to verify the information provided. Additionally, project-specific information may be requested from the Applicant, regulatory agencies, or project owners during the licensing investigation.
I, upon my oath, do state that the above information is a true and correct statement.
I further affirm, upon my oath, to follow Title 40 of the Oklahoma Statutes, Sections 450 through 456 as amended, and any rules adopted by the Commissioner of Labor relative to any procedures and standards adopted thereto, and agree to abide by all Child Labor Laws, Federal and State, and any and all Workers Compensation Insurance Laws of the State of Oklahoma. I swear that none of the persons listed above have unpardoned felony convictions in any State or Federal court. I understand that a violation of any law or rule may subject my license to be suspended or revoked, or subject me to cease and desist orders, injunctive measures, and criminal penalties for willful violation.
Applicant’s Signature Date

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3017 N. STILES., OKLAHOMA CITY, OKLAHOMA 73105 ∙ www.labor.ok.gov ∙ PHONE: (405)521-6464 ∙ FAX (405) 521-6016
Revised 2011-Jan Oklahoma Department of Labor
Mark Costello
COMMISSIONER OF LABOR
ASBESTOS ABATEMENT CONTRACTOR APPLICATION
☐ NEW ☐ RENEWAL LICENSE #
1. Applicant’s Name - 1st Responsible Party
2. Doing Business As:
3. Social Security Number
4. Date of Birth
3. Address
4. City
5. State
6. Zip
7. Phone
8. FAX:
List the name and address of the Service Agent:
1. Name:
2. Title & Capacity:
3. Address
4. City
5. State
6. Zip
List the names and home addresses of the officers, principals, partners and proprietors.1. Name: 2. Title & Capacity:
3. Address
4. City
5. State
6. Zip 1. Name: 2. Title & Capacity:
3. Address
4. City
5. State
6. Zip 1. Name: 2. Title & Capacity:
3. Address
4. City
5. State
6. Zip 1. Name: 2. Title & Capacity:
3. Address
4. City
5. State
6. Zip
2nd Responsible Party (If applicable)
Name of Responsible Party:
Please indicate all current Oklahoma asbestos licenses and the license number: CHECK TYPE LICENSE LICENSE NUMBER CHECK TYPE LICENSE LICENSE NUMBER
Worker
Inspector
Supervisor
Project Designer
Mgmt. Planner
FOR OFFICE USE ONLY
FOR OFFICE USE ONLY
Date
DEO
Receipt No.
License No.
Asbestos Admin Approval/Date Type of Payment
1 2 3
#
Endorser 3017 N. STILES., OKLAHOMA CITY, OKLAHOMA 73105 ∙ www.labor.ok.gov ∙ PHONE: (405)521-6464 ∙ FAX (405) 521-6016
Revised 01/09/2012 PLEASE SUBMIT COPIES OF THE FOLLOWING:
1. Original Contractor/Supervisor training class and all subsequent refresher classes*
2. Other asbestos training classes*
3. Proof of workers’ compensation insurance coverage or a notarized statement explaining why such coverage is not mandated by law.
*Training must have been provided by an educational institution, government agency or labor union and must have been accredited by the U. S. Environmental Protection Agency.
I hereby authorize the educational institution(s) to release verification of completion of the courses presented in this application.
I, upon my oath, do state that the above information is a true statement, and further state that I am not under any type of disciplinary action, including license revocation or suspension, by any State or political division thereof, or by the United States government, for any illegal or improper activity, civil or criminal, involving asbestos-containing material.
Applicants Signature Date
Please list all locations in all states in which the Contractor has performed abatement of friable asbestos materials. Include the name and address of the local asbestos procedure enforcement agency(s) for each location. 1. Name of contracting authority:
Address of contracting authority:
Name of enforcing agency:
Address of enforcing agency:
City
State
Zip
Project name:
Project address:
City
State
Zip
2. Name of contracting authority:
Address of contracting authority:
Name of enforcing agency:
Address of enforcing agency:
City
State
Zip
Project name:
Project address:
City
State
Zip
3. Name of contracting authority:
Address of contracting authority:
Name of enforcing agency:
Address of enforcing agency:
City
State
Zip
Project name:
Project address:
City
State
Zip 3017 N. STILES., OKLAHOMA CITY, OKLAHOMA 73105 ∙ www.labor.ok.gov ∙ PHONE: (405)521-6464 ∙ FAX (405) 521-6016
Revised 2011-Jan OAC 380:50-5-5 of the Abatement of Friable Asbestos Materials Rules states: Licensing of Asbestos Abatement Contractors are as follows: (1) Applications shall be submitted on forms prescribed by the Commissioner. Submission of such application shall include a non-refundable one thousand dollar ($1,000.00) processing fee. (2) After the statutory one hundred twenty (120) day waiting period, if a Contractor’s application is accepted, the Contractor will be notified by the Commissioner and required to submit at that time the five hundred dollar ($500.00) license fee. (3) The applicant shall designate a minimum of one, or a maximum of two, responsible parties to be named on the license. Such responsible parties shall have and maintain the training credentials required for licensing. Documentation of satisfactory completion of the required training and all subsequent refresher training shall accompany the application. (A) In the absence of such responsible party in the employee of the Contractor, the Contractor will not be allowed to perform asbestos abatement work in the State of Oklahoma. (B) The responsible party shall have successfully completed and shall have documentation provided for not fewer than two asbestos training courses. One such course shall be an Asbestos Abatement Supervisor’s course which fully meets the requirements of OAC 380:50-6-3 and 380:50-6-8. The Commissioner shall maintain updated lists of additional training courses acceptable for licensing. (C) Responsible parties may be changed or added to the license at any time, by paying a fee of fifty dollars ($50.00) per change or addition. Documentation of satisfactory completion of required training and all applicable subsequent refresher training shall be submitted. (4) Prior to issuance of the license, the Contractor must have a respirator program meeting all requirements of OSHA or DOL, whichever is most stringent. (5) Licenses shall be issued for a period of one year. (6) No Contractor may perform any asbestos abatement after expiration of the license. (7) If a Contractor allows the license to lapse for more than thirty (30) days, the license may not be renewed, and licensing will be permitted only after meeting all requirements for a new license, including the one hundred twenty (120) day waiting period. (8) License applicants must be of good character. Conviction for a felony by an applicant, if a proprietor or partner; by an officer, if a corporation; or by a responsible party, shall be grounds for denial of, or revocation of, a Contractor’s license. (9) The Commissioner may refuse to issue an Asbestos Abatement Contractor’s license to any applicant, if there are records of Notice of Violation (NOV) of NESHAP regulations by the applicant, or any principal, partner, or officer of the applicant’s firm or associated firms, as maintained by EPA.
4. Name of contracting authority:
Address of contracting authority:
Name of enforcing agency:
Address of enforcing agency:
City
State
Zip
Project name:
Project address:
City
State
Zip
Please submit the following with this application:
1. Approved Respirator Program
2. Operations & Maintenance Program
Please check one of the following:
NON-EXEMPT
New applicants only must submit check or money order for $1,000.00 made payable to the Oklahoma Department of Labor as a non-refundable application fee.
OR
EXEMPT
The state and political subdivisions thereof shall be exempt from any certification fees when such entities act as a contractor.
In accordance with Title 40, Section 452, Oklahoma Statutes as revised, there is a mandatory one-hundred twenty (120) day waiting period to allow the Asbestos Division to investigate the work record of the Applicant. The license may be denied to an Applicant whose past performance for abatement of friable asbestos does not comply with Federal and other State’s requirements.
Providing false or incomplete information on this Affidavit/Application will be grounds for rejection of this application, or for suspension or revocation of the license, if issued.
At such time as the application and respiratory program are approved, the Applicant will be so notified. The Applicant at that time will submit the Five-hundred Dollar ($500) annual license fee, and the license will be subsequently issued. 3017 N. STILES., OKLAHOMA CITY, OKLAHOMA 73105 ∙ www.labor.ok.gov ∙ PHONE: (405)521-6464 ∙ FAX (405) 521-6016
Revised 01/09/2012 Foreign corporations must be registered with the Oklahoma Secretary of State.
Any supplemental information submitted with this application must be signed by the Applicant and notarized.
All agencies listed in this form may be contacted by the Oklahoma State Department of Labor to verify the information provided. Additionally, project-specific information may be requested from the Applicant, regulatory agencies, or project owners during the licensing investigation.
I, upon my oath, do state that the above information is a true and correct statement.
I further affirm, upon my oath, to follow Title 40 of the Oklahoma Statutes, Sections 450 through 456 as amended, and any rules adopted by the Commissioner of Labor relative to any procedures and standards adopted thereto, and agree to abide by all Child Labor Laws, Federal and State, and any and all Workers Compensation Insurance Laws of the State of Oklahoma. I swear that none of the persons listed above have unpardoned felony convictions in any State or Federal court. I understand that a violation of any law or rule may subject my license to be suspended or revoked, or subject me to cease and desist orders, injunctive measures, and criminal penalties for willful violation.
Applicant’s Signature Date